Age and the treatment of lung cancer.

BACKGROUND: The average age of patients with lung cancer is increasing and there are large numbers of elderly symptomatic patients with this common disease. However, there are few data on how the treatment of this group differs from that of younger patients. METHODS: From 1 January 1990 information was collected for the Southend Lung Cancer Registry on all patients with a diagnosis of lung cancer in a geographically well defined health district of the UK with a population of 325,000. Every effort was made to find new cases from all departments of the hospital, including all clinical diagnoses, histopathological and cytological reports, and necropsies. All death certificates in the district were examined, irrespective of age, for any diagnosis of lung cancer. This therefore included any patient not seen by the hospital services. The differences in initial treatment have been analysed for three age groups: under 65, 65-74 years, and over 75. RESULTS: The 563 cases of lung cancer diagnosed during a 30 month period were included in the study, of whom 240 (43%) were aged over 75 years. The overall mean age was 71 years (range 31-95). The incidence of lung cancer in the general population was 69 per 100,000, but in men over 75 years of age it rose to 751 per 100,000. For all patients the active treatment rate (chemotherapy, surgery, or radiotherapy) was 49%, but for patients not reviewed by a chest physician (n = 86) it was only 21%. There were large differences in initial treatment between age groups. For patients with non-small cell lung cancer (NSCLC) reviewed by a chest physician, surgery was undertaken in 18% of those under 65, 12% of the 65-74 age group, and 2.1% of those over 75. For patients with small cell lung cancer (SCLC) reviewed by a chest physician, 79% of those aged under 65, 64% of the 65-74 age group, and 41% of patients aged over 75 received chemotherapy. In patients with NSCLC reviewed by a chest physician, chemotherapy was given to 21% under 65, 6.4% in the 65-74 age group, and none over 75. If no histological diagnosis was made 37% of patients aged under 75 and only 5.4% of those over 75 received either surgery, radiotherapy, or chemotherapy. Patients not reviewed by a chest physician were less likely to have had a histological diagnosis. Differences in treatment rates with age persisted even after allowing for performance score status at presentation. CONCLUSIONS: Lung cancer is a common disease in the elderly and, in our district, 43% of patients were aged 75 or over at presentation. Age alone appeared to be a major factor in influencing treatment choices, and treatment was more likely if histological confirmation was obtained. Further detailed analysis of the reasons for the differences is needed. Patients referred to chest physicians were more likely to have both histological confirmation and active treatment. This study supports the contention that all patients with a diagnosis of lung cancer, irrespective of age or condition, should be assessed by an accredited chest physician.

A randomised trial of planned versus as required chemotherapy in small cell lung cancer: a Cancer Research Campaign trial.

In a study of chemotherapy as palliative treatment, 300 patients with untreated limited and extensive stage small cell lung cancer (SCLC), who did not have progressive disease after the first cycle of chemotherapy, were randomised to receive either regular 'planned' chemotherapy or chemotherapy given 'as required' (AR). All patients received the same chemotherapy: cyclophosphamide 1 gm m-2 i.v., vincristine 2 mg i.v., and etoposide 120 mg m-2 i.v. on day 1, and etoposide 100 mg b.d. orally on days 2 and 3. Planned chemotherapy was given regularly every 3 weeks. AR chemotherapy was given for tumour-related symptoms, or for radiological progression of disease. Both groups of patients were assessed every 3 weeks and a maximum of eight cycles of chemotherapy was given. A detailed quality of life assessment was made using daily diary cards. The median survival (MS) of patients given AR chemotherapy was not significantly worse than those receiving planned treatment [MS: Planned = 36 weeks (95% C.I. 32-40 weeks), AR = 32 weeks (95% C.I. 28-37 weeks) P = 0.960]. In the AR patients the median interval between treatments was 42 days. On average AR patients received half as much chemotherapy as planned patients. AR patients with a treatment-free interval (TFI) of more than 8 weeks between the first and second cycles of chemotherapy survived longer than those in whom this interval was less than 4 weeks; [MS: TFI greater than 8 = 47 weeks (95% C.I. 32-53 weeks); TFI less than 4 = 24 weeks (95% C.I. 17-34 weeks) P = 0.013]. Contrary to expectation, in the quality of life assessment the AR patients scored themselves as having more severe symptoms than patients receiving planned treatment. AR chemotherapy is a novel method of attempting to use cytotoxic drugs palliatively, which resulted in less drug treatment for approximately equivalent survival. However the palliative effect seen with as required treatment was less satisfactory than with planned chemotherapy.

Duration of chemotherapy in small cell lung cancer: a Cancer Research Campaign trial.

A total of 610 patients with small cell lung cancer were entered into a randomised trial designed to assess the effect of duration of initial chemotherapy on survival. Patients were randomised to receive either four or eight courses of cytotoxic chemotherapy with cyclophosphamide, vincristine and etoposide and also randomised to receive, on disease progression, either second line chemotherapy (methotrexate and doxorubicin) or symptomatic treatment only. In the whole study 196 (32.1%) had limited disease and 414 (67.9%) extensive disease. During initial chemotherapy the response rate (complete and partial responses) after four courses of treatment was 61% with no significant increase in patients receiving eight courses (63%). In those randomised to receive relapse chemotherapy the response rate was improved slightly for those who had originally received four courses of chemotherapy (25.6%) over those receiving eight (18.7%). The overall results show that of the four possible treatment randomizations, four courses of chemotherapy alone is inferior in terms of overall survival (30 weeks median survival) to the other three treatment options (39 weeks median survival, P less than 0.01). In patients responding to initial chemotherapy the disadvantage of four courses of chemotherapy alone was apparent (median survival of 40 weeks versus 49 weeks, P = 0.003) but not if drug treatment was given on relapse. The study shows that limiting treatment to four courses of chemotherapy alone is associated with inferior survival, but this is not the case if chemotherapy is given at relapse.

Pulmonary necrobiotic nodules without rheumatoid arthritis.

Pulmonary necrobiotic nodules are the least common of the pulmonary lesions associated with rheumatoid arthritis. Histologically they are identical to subcutaneous rheumatoid nodules. Systemic rheumatoid arthritis usually precedes the development of pulmonary nodules. Seven cases where the pulmonary nodule appeared before or without the development of systemic rheumatoid arthritis are described. The typical histological and radiological features of necrobiotic nodules were found in each. In five of the seven the nodules were in more than one site and in five there were cavitating nodules. Spontaneous improvement occurred in one case. Pulmonary nodules preceded systemic rheumatoid arthritis in three cases and in the remaining four cases systemic rheumatoid arthritis has not yet appeared despite prolonged follow-up. In all patients, tests for rheumatoid factor have remained negative. The absence of circulating rheumatoid factor and systemic rheumatoid arthritis cannot exclude the diagnosis in these cases if the histological diagnosis is accepted as conclusive.

Prevalence and morbidity of heart block in Devon.

In a survey in the Exeter area 139 patients with some degrees of abnormal atrioventricular conduction were notified by 282 family doctors. Per 100,000 of the population the prevalence of second-degree and thrid-degree heart block was estimated to be 17.3, of complete block past or present 15.6, and of complete block at the time of survey 13.1. Heart block was commoner in men than women, the sex ratio being 1.4 to 1; its prevalence increased steeply with age, and the morbidity rate was less than that reported by others. If the morbidity figures quoted in this survey are representative of the general population, it reaffirms the policy that pacemakers should be recommended for selected patients only.